The use of complementary and alternative medicine for functional gastrointestinal disorders among the saudi population

Background and objective Complementary and alternative medicine (CAM) is a common practice among patients, who experience functional gastrointestinal disorders (FGID). Among the Saudi population, less is known about CAM use for FGID. Therefore, this study aimed to determine the prevalence of CAM utilization for FGID amongst the Saudi population and determine the types of CAM used for treatment. Method A cross-sectional study was carried out in Riyadh, Saudi Arabia during February 2023 through social media platforms using questionnaires adopted from the literature. There were three sections in the questionnaire including demographic information, questions to determine the prevalence of CAM use for FGID, the types of FGID, and the types of CAM utilization, and questions on the sources of information about CAM. Multivariable logistic regression was applied to find factors associated with CAM use. All statistical analyses were performed using SPSS version 26. Results A total of 828 people participated in this study. The overall prevalence of CAM use for FGID problems was 87.2 %. There were no significant differences in CAM use for FGID problems between men (87.5 %) and women (86.3 %) (P = 0.727). The most commonly used types of CAM for FGID were ginger (73.4 %), chamomile (66.6 %), mint (61.6 %), turmeric (59.0 %), anise (55.5 %), fennel (43.1 %), and Activia yogurt©️ (42.7 %). The most common FGID disorders for utilizing CAM were IBS (29.9 %), followed by constipation (29.8 %), dyspepsia (22.7 %), and bloating (17.0 %). In the multivariable regression, age, gender and employment status did not have an impact on the odds of using CAM. The subjects who had high school, university, and postgraduate education had significant odds ratios of CAM use (OR = 2.73; 95 % CI: 1.22–6.13), (OR = 4.18; 95 % CI: 2.03–8.58), and (OR = 20.85; 95 % CI: 5.51–78.80), respectively, compared to subjects who did not complete high school. Participants who had private insurance had a significant odds ratio (OR = 0.27; 95 % CI: 0.14–0.55) compared to governmental insurance. Conclusion The use of CAM among the Saudi population is alarmingly high; however, the lack of standardized medical recommendations and treatment options may be the cause. Although there were no significant gender differences, participants with higher educational levels and private insurance coverage were more likely to use CAM for FGID. Patients suffering from FGID and limited access to medical advice and treatment options are vulnerable to being exposed to dubious and incredible information sources. Expanding access to preventative medical services, funding governmental medical websites to provide credible information, educating healthcare professionals about FGID, and conducting more research in safe and effective treatments for FGID is recommended.


Introduction
Complementary and alternative medicine (CAM) is a broad category of treatments, procedures, and supplies that claim to prevent or treat disease (Aljawadi et al., 2020).Because there is inadequate evidence to support the safety and efficacy of CAM therapies, they are not a part of standard medical care (Aljawadi et al., 2020, Barnes, Bloom andNahin, 2008).Alternative interventions are utilized in place of traditional medicine, while complementary interventions are used in addition to conventional therapy (Barnes, Bloom and Nahin, 2008).The most common types of CAM are herbal products, acupuncture, medical massage, homeopathy, chiropractic treatment, and reflexology (Kemppainen et al., 2018, Frass et al., 2012).
The use of CAM among the general population is widespread globally (Harris et al., 2012).The three countries with the highest reported rates of CAM usage were all in East Asia: Malaysia, (76 %), Japan (76 %), South Korea (75 %) (Harris et al., 2012).Although an earlier study in 2004 by Barnes et al. among adult in the United States (US) revealed that 62 % of American adults may use some types of CAM, more recent surveys indicate that the prevalence is approximately 38 % (Barnes et al., 2004).In Europe, 52 % of Australians (Harris et al., 2012), 49 % of French, and 46 % of Germans reported using CAM therapy at some time in their life (Fjaer et al., 2020, Kemppainen et al., 2018).In the Kingdom of Saudi Arabia (KSA), between 65 % and 80 % of people reported using CAM (Al-Faris et al., 2008, Elolemy andAlBedah, 2012), while the use of herbal medicine was 62.7 % (Syed et al., 2022).The most prevalent forms of herbal medicine are ginger extract (Al-Yousef et al., 2019;Syed et al., 2022), followed by garlic extract (Syed et al., 2022), cinnamon (Al-Yousef et al., 2019;Syed et al., 2022), and lemongrass (Syed et al., 2022).
Herbal medications may be beneficial, but concerns about quality and safety must be considered.The use of inferior raw materials with insufficient quality control measures may compromise the efficacy of herbal medicines.Herbal remedies are generally perceived as clean and natural, which makes them seem less risky than conventional medications.Unfortunately, it is not possible to conclude that these medications are totally devoid of problems such as toxicity and side effects.For example, several herbal remedies exacerbate the effects of anticoagulants and interact with cytochrome P450 enzyme systems, which are crucial to medication metabolism (Al Akeel et al., 2018).
Safety is a key component of quality control and a vital element in the provision of herbal medicines and products for health care.The World Health Organization has published guidelines on how to safely use and monitor these medications (World Health Organization, 2004).Herbal medications are classified as non-prescription medicines or goods appropriate for self-care; therefore, prescriptions are not needed to purchase them in many countries.Typically, herbal medicine providers of CAM are not medical professionals.These include community pharmacists and nurses, as well as practitioners of CAM.Monitoring the safety of over-the-counter herbal medications should involve all providers of herbal medicines.The involvement of pharmacists and nurses in this field is growing, and they contribute significantly to safety monitoring.Medical professionals including doctors, nurses, and pharmacists might not be knowledgeable about the effects of herbal medicines on the health of their patients.Making informed decisions about diagnosis and treatment also requires an appropriate knowledge base.In addition, other healthcare professionals who do not routinely prescribe herbal remedies have limited knowledge about these products and how to utilize them.Herbal medicine education is also necessary for medical personnel who operate in poison control centers and health information services.Many consumers of CAM erroneously associate products from natural origins with the absence of adverse effects and subsequently do not consider it important to disclose their use of CAM to their physician.Similarly, individuals frequently neglect to disclose to their herbal medicine providers that they use other medications.In order to prevent potentially dangerous sequalae from the abuse of herbal medicines, education is essential for consumers, healthcare professionals, and herbal medicine providers.
Although FGID affects a significant portion of the general population, there are very few effective treatments.Treatment includes a biopsychosocial approach including diet and lifestyle modifications, treatment of associated psychiatric comorbidities, and medications to address underlying diseases (Fikree and Byrne, 2021).The majority of current therapies are prescribed to relieve symptoms rather than treating the underlying causes of the condition.Patients frequently seek alternative and complementary medical interventions because they are dissatisfied with traditional medical therapy (Chen et al., 2017).The use  of alternative and complementary medicine varies based upon not only the type of disease, but also the culture and specific country of the patient (Chen et al., 2017).Its utilization in the field of gastroenterology is frequently seen among patients with FGID (Chen et al., 2017).The reported prevalence of CAM usage in London was 50.9 % for IBS and 49.5 % for inflammatory bowel disease (IBD) (Langmead, Chitnis and Rampton, 2002).The primary CAM therapies that have been used to treat FGID have involved dietary, drug/biological, psychological, herbal medicine, and behavioral therapies (Stake-Nilsson et al., 2011, Chen et al., 2017).Therefore, the aim of this study was to determine the prevalence of CAM utilization for FGID amongst the Saudi population and determine the types of CAM used for treatment.

Study design
A cross-sectional study was carried out in Riyadh, KSA during February 2023.Data was collected through a questionnaire published on social media platforms such as WhatsApp© and X© (formerly known as Twitter).

Sample size
Based upon the previous prevalence rate of CAM reported in KSA of 30 % (Elolemy. et al.,2012), a sample size of 323 was calculated using the following equation: where n is the minimum sample size, z is the constant (1.96), p is the prevalence of CAM among the Saudi population (30 %), q is (1 − p), Z is the standard normal deviation of 1.96 corresponding to the 95 % confidence interval, and d is the desired degree of accuracy or tolerated margin of error which is 5 % (0.05).

Questionnaire development
Data was gathered using a structured self-questionnaire prepared in Arabic.The questionnaire used in this study was created after thoroughly evaluating the literature on FGID, CAM use, and types of CAM using for FGID.There were three sections in the questionnaire: (1) demographic information, (2) questions to determine the prevalence of CAM use within the past month and current use of FGID, the types of FGID, and the types of CAM, and (3) questions on the sources of information about CAM.The first draft of the questionnaire was reviewed by research experts in the pharmacy practice field.Then, a pilot study was conducted in a randomly selected sample of 26 respondents to get their feedback on how to make the questionnaire more user-friendly.The Cronbach's alpha was 0.731.The data was collected using convenience sampling by using social media as the main platform for data collection.For the purpose of data collection, a researcher was appointed.The data was collected until the required number of responses obtained by sending reminders for completing the questionnaires.In addition to obtaining the maximum number of responses, a snowball technique was utilized, where a participant who received the survey would suggest or recruit participants.

Data analysis
The data was analyzed using the Statistical Package for the Social Sciences (SPSS) (version 26) for Windows (SPSS Inc., Chicago, IL, USA).Descriptive statistics were used to summarize the demographic features.The Chi-square test was employed to investigate the relationship between the demographic data and CAM use.Bivariable and multivariable logistic regressions were applied to determine factors associated with

Results
A total of 828 people participated in this study.Of the 828 participants, 601 (72.6 %) were males.The majority of respondents reported that their age was between 18 to 25 years old.Approximately 42 % of respondents held a university degree.Table 1 provides more details on the respondents' demographic data.The overall prevalence of CAM use for FGID problems was 87.2 %.There was no significant difference in CAM use for FGID problems between men (87.5 %) and women (86.3 %) (P = 0.727).Among age groups, adults in the age group greater than 55 years used CAM significantly more (97.3%) than other age groups (P < 0.001).
Table 2 shows the multivariable logistic regression of factors associated with utilization of CAM.In the bivariable regression, age and employment status did not have an impact on the odds of using CAM.The subjects who had high school, university, and postgraduate education had significant odds ratios of CAM use (OR = 2.73; 95 % CI: 1.22-6.13),(OR = 4.18; 95 % CI: 2.03-8.58),and (OR = 20.85;95 % CI: 5.51-78.80),respectively, compared to subjects who did not complete high school.Participants who had private insurance had a significant odds ratio (OR = 0.27; 95 % CI: 0.14-0.55)compared to governmental insurance; however, Hosmer-Lemeshow test was not significant (=0.370).

Discussion
According to our knowledge, this is the first study conducted to determine the prevalence of use of CAM to treat gastrointestinal disorders in KSA.Previous studies have focused primarily on the prevalence of the use of CAM in KSA.A recent national survey was conducted by Al-Jawadi et al. among elderly people to determine the prevalence of the use of alternative medicine.This study found that the prevalence of CAM use was 62.5 % (Aljawadi et al., 2020).Another study was conducted in Riyadh, KSA among 740 adults to determine gender differences in CAM utilization according to personal practices and opinions.It was reported that approximately 36.0 % of participants used CAM (Abdalla et al., 2020).
In this study, the prevalence of CAM use for GI disorders was high amongst the Saudi population (87.2 %).Similar to the differences in languages, traditional medications, and cultures, the prevalence of CAM use for GI disorders differs between studies and countries.For instance, the prevalence of CAM use for GI disorders among adults has been reported to be between 23 % to 44 % and 63.5 % for American and Australian adults, respectively (Gan et al., 2018).Yoon et al. utilized an online survey to identify the self-reported use of CAM, including dietary supplements, to treat GI symptoms and found that 84.5 % of US respondents used herbal medicines (Yoon et al., 2018).
The multivariable logistic regression showed an excellent fit, according to the Hosmer-Lemeshow test (P = 0.370).Regression analysis showed that there were no noticeable differences in CAM use by gender.This result is similar to several published studies (Thomas and Coleman, 2004, Jawahar et al., 2012, Abdalla et al., 2020, Aljawadi et al., 2020).Nonetheless, a number of studies have reported that adolescent girls are more likely to use CAM (Kristoffersen et al., 2014, Alwhaibi and Sambamoorthi, 2016, Carlsson, Vestin and Bjerså, 2020).This study showed that CAM utilization may be influenced by a combination of factors including education levels, income, and other socioeconomic categories like employment status.Previous studies have reported that the use of CAM was more common among people with higher educational levels (Grundmann, 2014).Contrary to that, a study conducted in KSA revealed that participants with low levels of education were more likely to use CAM than those with higher education levels (Syed Faisal Zaidi et al., 2022).
In the present study, the most common type of CAM used for FGID was ginger (73.4 %).Ginger is a valued dietary supplement that has carminative action, decreases intestinal pains, lowers the strain on the lower esophageal sphincter, and guards against bloating, gas, and dyspepsia (Nikkhah Bodagh, Maleki and Hekmatdoost, 2018).It has been reported that the most common CAM utilized for IBS is ginger (van Tilburg et al., 2008).About 62 % of participants used peppermint extracts for FGID.It has been reported that peppermint leaves are commonly used to treat digestive disorders symptomatically (Begas et al., 2017).In addition, peppermint is one of the most extensively studied natural CAM remedies for the treatment of functional dyspepsia, bloating, and epigastric pain, and has many effects such as antiemetic properties and a spasmolytic effect (Begas et al., 2017, Deutsch, Levitt andHass, 2020).It was interesting that most of our subjects revealed that they use turmeric for FGID.According to a meta-analysis that involved five clinical trials, curcumin, turmeric's major active ingredient, was shown to be generally effective in decreasing IBS symptoms (Lopresti et al., 2021).Also, curcumin can be used as an adjuvant in the treatment of H. pylori infection (Kwiecien et al., 2019).Approximately 43 % of subjects consumed probiotic yogurt (Activia yogurt© ) for FGID.Studies have reported that probiotic yogurt is effective for gut health, including disorders such as FGID, IBS, and ulcerative colitis, and patients reported that it significantly reduced their stomach discomfort and flatulence (Kim et al., 2019, Hadjimbei, Botsaris andChrysostomou, 2022).About 35 % of subjects reported that they used honey to treat FGID.This finding is supported by the clinical literature.Honey has been proposed as a possible treatment for a number of gastrointestinal tract diseases including dyspepsia, periodontal disease, and other oral problems.It has also been considered as an effective component of oral rehydration therapy.According to in vitro research, honey may have bactericidal effects on H. pylori (Samarghandian, Farkhondeh andSamini, 2017, Schell et al., 2022).A summary of evidence-based recommendations related to selected CAM therapies can be found in Table 3.
Physicians and pharmacists were identified as trusted sources of information regarding CAM use.Although physicians are often consulted initially, approximately only 25 % receive education about CAM in required medical college courses and only 15 % were exposed to CAM during residency training (Patel, Kemper et al. 2017).Furthermore, post-graduate physician residents reported a "don't ask, don't tell" culture between patients and their physicians.Although they believed that up to 40 % of patients use CAM, they believed that less than 20 % spontaneously divulge CAM use and they estimate that hey routinely ask patients about CAM use less than 20 % of the time.Physician interest in learning about CAM also tends to decline after the preclinical years of medical school (Joyce, Wardle et al. 2016).Foley et al. conducted a systematic review and meta-analysis of the rate of disclosure of CAM use to medical providers (i.e.primarily physicians) and reported that 67 % of patients do not inform their physicians about CAM use (Foley, Steel et al. 2019).
Pharmacists are considered one of the most important healthcare providers well-suited to give advice to the users of CAM by presenting evidence-based medical counseling to ensure the safety of these products (Farrell, Ries et al. 2008).Pharmacists are well positioned to inform patients on the usage, effectiveness, side effects, and possible interactions with prescription drugs with dietary and herbal supplements regardless of how these products are regulated (Ng et al., 2021).Moreover, the majority of dietary and herbal supplements users are more likely to confide in pharmacists about their use of these products than to their physicians (Kheir, Gad et al. 2014).A study carried out in Australia found that 87-92 % of customers thought pharmacists could give them sufficient, trustworthy information on the efficacy and safety of dietary and herbal supplements (Mehralian, Yousefi et al. 2014).It must be emphasized that it is important for pharmacists to have adequate knowledge regarding these products in order to provide patients with accurate recommendations about dietary and herbal supplements (Ng, Tahir et al. 2021).
The authors would like to acknowledge some limitations of the study.This was a cross-sectional study and the possibility of selection  Fennel seed and fennel seed oil have been used as stimulant and carminative agents in doses of 5 to 7 g and 0.1 to 0.6 mL, respectively.
(continued on next page)  biases cannot be ruled out.Participation of specific populations such as the elderly and patients of lower socioeconomic statuses may have been limited due to lack of access to the survey.The possibility of recall bias may have influenced the results since self-reported data was used.Furthermore, there may have been demographical bias due to the fact that FGID is most commonly reported in females; however, a larger proportion on males reported symptoms in our study.Therefore, these limitations may affect the generalizability of study findings.

Conclusion
The use of CAM among the Saudi population is alarmingly high; however, the lack of standardized medical recommendations and treatment options may be the cause.Although there were no significant gender differences, participants with higher educational levels and private insurance coverage were more likely to use CAM for FGID.Patients suffering from FGID and limited access to medical advice and treatment options are vulnerable to being exposed to dubious and incredible information sources.Expanding access to preventative medical services, funding governmental medical websites to provide credible information, educating healthcare professionals about FGID, and conducting more research in safe and effective treatments for FGID is recommended.

Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Table 1
Univariable and bivariable analyses of CAM utilization for FGID among Saudi participants (N = 828).

Table 2
Bivariable and multivariate logistic regression of factors associated with utilization of CAM.

Table 3
An evidence-based summary of selected CAM methods.